Provider Demographics
NPI:1457733099
Name:CENTER FOR PSYCHIATRIC WELLNESS, PLLC.
Entity Type:Organization
Organization Name:CENTER FOR PSYCHIATRIC WELLNESS, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:OBANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-831-6007
Mailing Address - Street 1:PO BOX 11137
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7217 CAMERON PARK DR
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-6167
Practice Address - Country:US
Practice Address - Phone:479-831-6007
Practice Address - Fax:479-782-1242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-78172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210878002Medicaid